Minor Treatment Consent (Consent Folder)

Consent for Treatment of a Minor
Today's Date

MonthDayYear
Date
Name of Minor*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent/Legal Guardian of Minor *
Please note, the parent/legal guardian completing this consent is confirming and declaring that there are no court orders preventing him/her from granting this authorization for the patient.
I consent for the following caregiver(s) to accompany the minor child to appointments at Vital Dermatology.
Please list name(s) and relationship to the patient.
I consent for the patient to bring his/herself to appointments at Vital Dermatology.

Yes, I understand the patient must be 16 years old.
By signing below, I understand I am authorizing the above listed caregivers to seek, obtain and authorize diagnosis and treatment by Dr. Jenna Beasley.

I understand this treatment may involve return medical care and treatment, emergency medical care and treatment.

I understand this treatment may involve procedures such a curettage (skin scraping), cryotherapy ("freezing" of a skin lesion), biopsy or excision.

I understand this consent may be REVOKED by the minor child upon the date of his/her 18th birthday.
Signature*

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Consent for Treatment of a Minor